Anna FCM5 Neuro.txt

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The conscious state depends upon appropriate communication between both cerebral hemispheres and the ..

RAS-reticular activating system

list the 7 levels of consciousness:

confusion

delirium

lethargy

obtunded

stupor

coma

A patient who is awake, alert, and oriented to person, place, time, and situation. The patient follows commands appropriately and is aware of his/her surroundings. on exam, an alert patient will open their eyes, look at you, respond completely and appropriately. They will respond to a normal voice tone.

conscious

The patient responds appropriately, however is disoriented, difficult to arouse, and may have memory impairment.

Memory issues are the most common

confusion

The patient is agitated, restless, resistant, and uncooperative, but alert. This is an acute, reversible state of confusion. Symptoms wax and wane. ...really easy to upset

delirium

The patient is in deep, prolonged unconsciousness. He/She appears drowsy. on exam, the patient will open his/her eyes, look at you, answer questions, then fall asleep. Will respond only to a loud voice.

lethargic

The patient appears more sleepy. You must provide some physical stimulus to arouse the patient. Answers to questions are confused. shake and shout

Obtunded

May require a sternal rub or Tina's nipple twist

Obtunded

The patient will respond only to a continuous painful stimulus. They may respond slowly or not at all. once the painful stimulus is halted, the patient returns to the unconscious state.

Stupor

An unresponsive state to any type of external stimulus. This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres. eyes remain closed

Coma

Coma is an unresponsive state to any type of external stimulus. This is caused by some type of compromise of the__ or diffuse, simultaneous insult to___

This is caused by some type of compromise of the RAS, or diffuse, simultaneous insult to both cerebral hemispheres.

Brain death is a clinical diagnosis. Perform the exam __ hours after onset of the insult creating brain death. May follow with another exam __ hours later (optional)

6 hours

Pt returns to ER one week later with altered mental status. Pt not responsive to loud voice. Must gently shake the pt to arouse. Speech is incomprehensible, opens eyes for a few seconds, then closes them again. What is his level of consciousness?

obtunded

18 y/o male college student found down in the bushes at a Widespread Panic concert. Initially responsive to only painful stimuli. Minutes later, patient responsive to voice. He is restless, agitated, uncooperative. Both pupils dilated and reactive to light. Abrasions to face, hands, and knees. LOC?Work up?

initially stupor, now delirious

drugs? diabetes?

less precise term that is frequently used synonymously with polyneuropathy, but can also refer to any disorder of the peripheral nervous system including radiculopathies and mononeuropathies.

peripheral neuropathy

specific term that refers to a generalized, relatively homogeneous process affecting many peripheral nerves, with the distal nerves usually affected most prominently.

polyneuropathy

Focal involvement of a single nerve, usually due to a local cause such as trauma, compression, or entrapment. Carpal tunnel syndrome is a common example.

mononeuropathy

Carpal tunnel syndrome is a common example of which type of neuropathy?

mononeuropathy

Most common nerve entrapment disorder. Due to compression at the flexor retinaculum, with resulting median nerve compression; results in weakness of supplied muscles DISTAL to this (e.g. index finger-thumb apposition task) and thenar muscle atrophy, and numbness along lateral portion of hand

carpal tunnel

carpal tunnel is a compression of which nerve?

median

treatment for carpal tunnel?

first, brace..if no better, surgical decompression

physical findings of median nerve compression?

1) a positive Tinel sign or a positive Phalen test

2) diminished or absent sensation to pin prick in the median nerve distribution

Due to compression (usually) at the elbow, with resulting weakness in hand intrinsics & hypothenar muscle atrophy; also associated with numbness @ medial aspect of hand

ulnar neuropathy - cubital tunnel syndrome

Chronic axonal polyneuropathies (eg, due to __ or __) are the most common of the polyneuropathies. Injury tends to be related to axon length; thus, longer axons are affected first, resulting in symptoms that begin in the lower extremities. Sensory symptoms usually precede motor symptoms

diabetes mellitus or uremia

History: Pain in leg (travels along nerve root, thus radiculopathy) may or may not be related to trauma or action; Exam: Use the motor and sensory exams to determine nerve root affected. A disc is between 2 levels, and will affect the LOWER nerve root e.g. L5-S1 HNP causes S1 radiculopathy, which may reveal ankle plantar flexion weakness and decreased sensation at the bottom of the foot; also + straight leg raise

herniated lumbar disc dz

treatment for herniated disc dz?

conservative, NSAIDs, PT, injections

if >4 weeks, get MRI

must give time for inflammation to resolve

The single best test to dx lumbar path; Indicated for patients with > 1 month of symptoms & signs of nerve root compression

MRI

etiologies of which syndrome: Sagging musculature related to aging, obesity, or heavy breasts.

Postural etiologies

Weakness of the trapezius muscles due to aging, inactivity, or nerve damage

thoracic outlet syndrome

when should you operate on thoracic outlet syndrome?

never, really

in a young female with facial pain in the trigeminal distribution, what must you r/o?

MS

Trigeminal neuralgia is mainly found in what age patients?

elderly

one of the most common causes of facial pain. sudden, usually unilateral, severe, brief, stabbing or lancinating recurrent episodes of pain in the distribution of one or more branches

trigeminal neuralgia

how should you workup trigeminal neuralgia?

1. MRI to r/o mass or lesion

2. dental exam

primary management of trigeminal neuralgia pt?

meds,

then injections

then radiosurgery

Ball's palsy is a lesion of which CN?

VII-facial

Diffuse facial nerve involvement manifested by paralysis of the facial muscles, with or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands. ACUTE onset, hours to 1 or 2 days max

Histopathology is consistent with an inflammatory and possibly infectious cause

CN 7

term: perception of movement where no movement exists

vertigo

term: transient loss of consciousness accompanied by a loss of postural tone with spontaneous recovery

syncope

Define: spinning, weaving, seasickness, ground rising and falling, rocking, merry go-roundnausea, vomiting, and diaphoresis may be presenttinnitus and hearing loss indicate injury to the auditory component of the 8th cranial nervenystagmus present or can be produced

vertigo

Vestibular problems: peripheral or central? cochlear or retrocochlear, occurs in isolation except for presence of timmitus or hearing loss

peripheral

Vestibular problems: peripheral or central?: vertigo in association with other brainstem deficits

Vestibular problems: peripheral or central? Nystagmus May be absent, can be bidirectional (vertical nystagmus almost always central in origin), latency and fatigability absent, not inhibited by ocular fixation

Vestibular problems: peripheral or central? Hearing loss or tinnitus not often present. Brain stem or cerebellar findings often present

central

is benign positional vertigo peripheral or central lesion?

peripheral

definition: common in elderly, experienced with certain positionssudden onset usually within a few seconds of assuming the triggering positionsymptoms stop after few minutes in same position, but will resume if position changesresolves within 6 months

benign positional vertigo (peripheral lesion)

dx: idiopathic endolymphatic hydrops, damages hair cells because of swelling of the semicircular ducts, tinnitus, pressure in ear, hearing loss with vertigo can be disabling, episodes paroxysmal, lasting minutes to hours, then decrease in frequency after multiple attacks only to recur in months or years

Meniere's disease (peripheral lesion)

Is Meniere's Dz peripheral or central lesion?

peripheral

Dx: secondary to viral infections of cochlea and labyrinth, pt. c/o vertigo, tinnitus, and decreased hearing following a URI, resolve in 1-6 weeks

Combining findings of nystagmus with findings from Romberg and Rinne testing favors (central or peripheral) lesion? ie; if slow phase of nystagmus moves toward same side as hearing loss, patient reports spining is away from the side of the hearing loss and the Romberg is positive and pt. sways toward the side of the hearing deficit.

peripheral

Dx: recurrent attacks, tinnitus/vertigo/unilateral hearing loss

Meniere's Dz

sensation of faintness or inability to maintain normal balance in standing or seated postion, sometimes assoc'd with confusion, anusea, weakness

dizziness

dx: a head sensation of abnormal movement or abnormal movement of the environment spinning

vertigo

Episodic auditory and vestibular disease characterized by sudden onset of vertigo, hearing loss, tinnitus and sensation of fullness in the affected ear.
The cause is unknown, but results in an overproduction or impaired absorption of endolymph in the inner ear.
Diagnosis is made on clinical history and detailed audiology tests; other investigations may be required to exclude other causes.
Dietary changes and diuretics may control symptoms in early stages of the disease; specific medical therapies for vertigo control can be trialed if required.
If symptoms persist despite maximal medical therapy, several surgical interventions are available.

Meniere's Disease

Common, often self-limited condition, but can be chronic and relapsing.
Diagnosis is based on a suggestive history and physical exam with a positive Dix-Hallpike maneuver or a positive supine lateral head turn. Other tests are not usually required.
Medication is not an effective treatment option.
Repositioning maneuvers are highly efficacious in resolving an episode of BPPV.
Surgery is highly effective but is reserved for intractable and severe cases.

Benign Positional Vertigo

Paresis = __
Plegia = __

Paresis = weakness

Plegia = paralysis

Hemi = ___
Para = __
Quadri (tetra)= __

Hemi = both limbs same side

Para = both lower extremities

Quadri (tetra)= all 4 extremities

Neuropathy or Myopathy:

Neuropathy or Myopathy: Typically manifests distally; Usually has associated sensory symptoms; Tend to be a endocrinopathy, affects distal extremities first; usually assoc with numbness/tingling, not just motor weakness

neuropathy (DMII is MCC)

Neuropathy or Myopathy: Typically manifests proximally first in the larger, anti-gravity muscles.; Not usually associated with sensory symptoms;

A chronic autoimmune disorder of the postsynaptic membrane at the neuromuscular junction in skeletal muscle. Characterized by muscle weakness that increases with exercise (fatigue) and improves on rest. Commonly presents with drooping eyelids, double vision, oropharyngeal and/or appendicular weakness and shortness of breath.

Myasthenia gravis

Tx for myasthenia gravis?

Treatments include anticholinesterases and immunotherapy. Thymectomy may be required.

Most patients enjoy good quality of life and normal lifespan due to advances in diagnosis and immunosuppressive treatment.

definition:
- aggregate of blood factors building on a vascular wall to the point of occlusion
- platelets/fibrin/trapped cellular elements, etc on an underlying plaque

thrombus leading to ischemic stroke

definition: clot, plug or detritus brought by blood circulation from another location to lodge in a smaller vessel

embolus leading to ischemic stroke

definition: Decreased flow if you are drowning or you have heart failure and the hearts not pumping blood to the brain

hypoperfusion leading to ischemic stroke

which type of stroke:
- Onset gradual or sudden
- Progression of symptoms is stepwise or stuttering
- Deficits focal to area of ischemia
- Happens when asleep or inactive (stuff building up on a wall, slower flow at night)
- Headache associated sometimes
- Usually preceded by TIAs for days or weeks

thrombosis leading to ischemic

Step wise ssx progression, stuttering: this is because when we're young, we have a good balance of build-up/break down mechanisms in place; but in older pt's, their artery is almost closed, buildup on both sides causing narrowing, when you build-up just a little more, suddenly it closes, but then the lytics kick in and opens it back up again, this happens cyclically so that they get worse each time, then get better and get worse

which type of stroke:
- Onset sudden
- Deficit usually maximal at onset
- Deficits focal to area of ischemia
- Onset with activity (due to high blood flow)
- Headache associated sometimes
- Not usually preceded by TIAs

embolus leading to ischemic strokes

which type of stroke:
- Sudden onset
- Neural deficit develops over minutes to hours
- Deficits focal to area of hemorrhage pressure, may have papilledema
- Usually awake and active prior to onset
- Headache very common
- No TIAs associated

intracerebral hemorrhage

- having a baby, pooping, sitting smoking a cig and drinking coffee

- High flow, high pressure situation, so HA is very common; stretching adjacent structures

which type of stroke:
- No deficit, no papilledema
- Mechanic who is lifting the car battery or 22 y/o mother who is in her first labor, these situations where they blow an aneurysm
- Always HA
- Instant HA, loss of consciousness
- Neck stiffness/N/V looks like meningitis - this is b/c all this blood irritates the meninges

subarachnoid hemorrhage

first line diagnostic test for stroke w/u?

CT NO CONTRAST!

this type of stroke will show up immediately bright white on CT scan with no contrast

intracerebral hemorrhage

this type of stroke takes 6-24 hours to show up hypodense on CT

ischemic

why should you do CT NO CONTRAST as first line for any type of suspected stroke?

Infarct (ischemic) takes 6-24 hours to become hypodense; CT doesn't tell you they've had an infarct, but it does tell you they haven't had a bleed this is important info to have

this type of stroke shows hazy in the peri-Willis space on CT, can have intraparenchymal extension

Subarachnoid hemorrhage

this study is almost immediately positive for ischemic stroke

MRI, but CT is first line

after you've done a CT no contrast and established that your stroke pt does not have a bleed, what's first line?

*Anticoagulation:

****Heparin drip first line

*Thrombolytics for emboli (clot busters)

Angioplasty for thrombosis

treatment for intracerebral hemorrhage stroke? (4)

Control BP to avoid rebleed

Correct any coagulopathy

Control ICP

Surgery for clot removal if feasible

tx for subarachnoid hemorrhage?

Surgery! endovascular coiling, slipping

6-8 days after a subarachnoid hemorrhagic stroke from this cerebral artery, you'll have vasospasm

ACA

apply triple H therapy:

- hemodilution hct 33-37%

- hypervolemia, using volume expanders w/o free water

- Albumin/plasmanate (hepatitis/AIDS)

- Dextran (0.05% anaphalaxis)

- hypertension

85% of all cerebral aneurysms leading to SAH arise from where in the circulation?

this imaging technique is the most reliable test for differentiating ischemic stroke from hemorrhage, but only 5% of acute ischemic strokes are visible in the first 12 hours

CT no contrast

what are 4 main risk factors for stroke?

HTN

smoking

diabetes

hyperlipidemia

T/F: as a primary preventative measure, antiplatelet agents reduce the risk of ischemic strokes in pt's without vascular risk factors

false

t/f: no evidence has been found to support the use of anticoagulation (heparin) in the management of acute stroke.

true. although heparin might reduce the risk of recurrent stroke in the short term, any benefit is offset by the increased risk of intracranial hemorrhage

___ therapy remains the treatment of choice to prevent recurrent thromboembolism in the majority of patients with stroke

antiplatelet

which is more common: viral or bacterial meningitis?

viral

__ meningitis typically occurs in the late winter and early spring, and __ meningitis is more common in the warm summer monehts

bacterial = winter/spring

viral = summer

4 etiologies of infectious acute meningitis

bacterial

viral

fungal

TB

2 etiologies for non-infectious acute meningitis?

SLE

sarcoidosis

This maneuver is positive for meningeal irritation when there is flexion of the hips and knees as the neck is passively flexed by the examiner

Brudzinski's sign

This maneuver is positive when there is pain and increased resistance to extending the knee, bilaterally

Kernig's sign

2 named signs which suggest meningeal irritation and inflammation

Brudzinski's and Kernig's signs

pathogenesis for meningitis

pt's have a precursor infection, like URI

The cilia of the mucosa in that area stop clearing and the bacteria are able to enter the skull area, cross the blood brain barrier and enter the CSF (which is usually sterile). Host defense mechanisms must also be ineffective in order for the bacteria to grow.

The top two causes of bacterial meningitis are __ and __. (80% of all cases of community-acquired bacterial meningitis in adults)

S. pneumonia and

N. Meningitidis

__ pathogen causes sporadic disease or epidemics in closed populations in the young (eg students in dormitories or schools)

Neisseria

A bacterial cause of meningitis in children is ___, with most cases by the age of 10

Haemophilus influenza

Most common bacterial pathogen of meningitis in adults

strep pneumo

Name that pathogen of bacterial meningitis:
- 2-25 years old
- Occurs in epidemics
- With DIC, purpuric skin rash, adrenal hemorrhage

Neisseria meningitidis

the over 60 age group usually gets this pathogen causing their bacterial meningitis

Listeria monocytogenes

The CSF of bacterial meningitis will show mostly...

PMNs

the CSF of viral meningitis will show mainly...

lymphocytes

glucose will be decreased in the CSF of bacterial or viral meningitis?

bacterial

always get this type of imaging for SAH

angiography

Dx:
- Inflammation of the brain parenchyma with degeneration and phagocytes of neural cells
- Etiology includes bacterial or viral causes although viral etiologies are more common

T/F: It may be impossible to differentiate between viral and bacterial meningitis clinically.

true:

Empiric antimicrobial therapy may be necessary as bacterial meningitis is associated with significant morbidity and mortality and requires urgent treatment. Lumbar puncture may confirm a diagnosis of viral meningitis and allow antibiotics to be stopped and the patient discharged from hospital.

tx: broad spectrum abx like rocephin b/c you're waiting for CSF results; he doesn't necessarily need to be in the hospital; viral men is usually self-limiting, will go away with fever reduction and analgesics for pain

- Dementia caused by direct HIV infection in the brain parenchyma
- Occurs in late HIV infection in those with severe immunosuppression
- A diagnosis of exclusion
- Usually occurs in the late stages of HIV infection
- Acquired and persistent cognitive decline with preserved alertness that usually dominates the clinical presentation
- Diagnosis?

AIDS dementia complex

Top 2 CNS infx assoc'd with AIDS

toxo

cryptococcus

Which of the following is INCORRECT regarding infections of the CNS?A. Meningitis is an infection of the leptomeninges and brain parenchyma
B. If bacterial meningitis is suspected, pretreatment with antibiotics could reduce yield of gram s stain, and cultures but not the CSF cell count from the initial LP
C. The choice of empirical antibiotic treatment for bacterial meningitis should be tailored to the age group and any physical findings that suggest a causative organism.
D. The bacteria that cause most community acquired meningitis transiently colonize the oropharynx and nasopharynx of health individuals and include Streptococcus pneumonia, Neisseria menigitidis and Hemophilus influenza

A. Meningitis is an infection of the leptomeninges and brain parenchyma

(this multiple choice question has been scrambled)

Which of the following is INCORRECT regarding infections of the CNS?
A. Have a detailed conversation with the child s pediatrician about immunizing the childB. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses
C. Give prophylaxis to the family of the child only, Acyclovir 10mg/kg four doses every 12 hours
D. Give dexamethasone 2mg/kg daily for ten days to the family of the child

B. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses

(this multiple choice question has been scrambled)

In a child with suspected acute bacterial meningitis treated with antibiotics, what would be the best next immediate plan of therapy?
A. Give dexamethasone 2mg/kg daily for ten days to the family of the child
B. Give prophylaxis to the family of the child only, Acyclovir 10mg/kg four doses every 12 hours
C. Have a detailed conversation with the child s pediatrician about immunizing the childD. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses

D. Give prophylaxis to close contacts of the child, Rifampin 600mg in four daily doses

(this multiple choice question has been scrambled)

You suspect that a patient has a CNS infection. Which one of the following is correct?
a. Viral infections are the most frequent cause of aseptic meningitis with most being caused by Enteroviruses or Herpes Virus
b. Several factors are involved in a person getting meningitis from a virus, including direct penetration through the venous sinuses
c. Only 1/3 of patients with meningitis have the classic presentation of headache, fever and stiff neck.
d. The CSF of viral meningitis would show an increased WBC count with a predominance of PMNs, low glucose, elevated protein and an increase opening pressure.

a. Viral infections are the most frequent cause of aseptic meningitis with most being caused by Enteroviruses or Herpes Virus

2/3 of patients have the classic presentation

D is wrong

B is characteristic of bacterial

Management of a patient, whom you suspect has viral meningitis, would include
A. Acyclovir 10mg/kg four doses every 12 hours to the patientB. Symptomatic and supportive treatment of the patient
C. Prophylaxis to close contacts, Rifampin 600mg in four daily doses
D. Prophylaxis to close contacts, Acyclovir 10mg/kg fours daily dosed for 10 days

B. Symptomatic and supportive treatment of the patient

(this multiple choice question has been scrambled)

You suspect that a child has a CNS infection. Which of the following is INCORRECT?
a. Encephalitis is suspected rather than meningitis because there are signs of altered consciousness
b. 1/3 of all encephalitis is caused by HSV, which has no preference for age, gender, season or geography
c. Although CSF may be normal in encephalitis, it usually shows a lymphocytic pleocytosis (0-1000 WBC/mcl)
d. The patient should be treated with Acyclovir until HSV encephalitis is ruled out

B is incorrect, only 10% is caused by HSV. It has an affinity for temporal lobe, is debilitating and treatable

You suspect a patient has a CNS infection. Of the following, which is NOT a COMMON opportunistic CNS infection associated with AIDS?
a. Candida
b. Toxoplasma gondii
c. Cryptococcus neoformans
d. Pneumocystis jirovecii
e. Progressive multifocal leukoencephalopathy

The correct answer is D;

- Pneumocystis jirovecii causes pneumonia not CNS infections.

- Progressive multifocal leukoencephalopathy is a demyleninating disease caused by a papovavirus. Symptoms are progressive dementia, visual impairment, seizures and or hemiparesis.

All of the following are correct concerning the AIDS Dementia complex (ADC) EXCEPT:
a. Also termed HIV encephalopathy, is dementia caused by direct invasion and infection of HIV to the brain
b. Cognitive impairment, altered motor performance and abnormal behavior with preserved alertness define the clinical triad
c. AZT therapy has been shown to retard and reverse impairment of this treatable dementia
d. Complications of untreated ADC include a near-vegetative state characterized by global dementia, mutism, and paraplegia or quadriplegia, although the patient usually remains arousable.

The correct answer is C. AZT therapy may retard the progression but will not reverse it.

Name that motor pathway: Voluntary movements, integrated skilled, complicated, or delicate movements. Ex: pianist, something that takes a lot of dexterity. It originates in the cerebral cortex, so if you have a stroke and damage the cerebral cortex, you may not gain back all your delicate movements

corticospinal tract

Name that motor pathway: automatic mvmts you don't think about - chewing, swallowing, blinking. Parkinson's or a stroke may lead to loss of these automatic movements. Damage to this is what causes the Parkinsonian "stare"

basal ganglia

name that motor pathway: coordinates and smoothes out muscle activity, controls posture. If your pt is drifting to one side while walking or standing, they fall to the side where the lesion is.

cerebellum

this type of tremor is unique to Parkinson's dz. Slow, rhythmic, only occurs at rest. AKA "pill rolling"

resting tremor

this type of tremor is most noticeable when holding your hands out straight. Bilateral fine, fast tremor found in normal individuals and assoc'd with caffeine, anxiety, hunger. Not relieved by EtOH or Beta-blocker

postural tremor

this type of tremor is worse when approaching a target. Assoc'd with voice, chin tremors, also seen in MS.; Better with EtOH, Beta-blocker

intention tremor

This type of tremor worsens as it nears target, but if you ask them to touch their nose and touch your finger, as their finger gets closer to your nose, their finger goes in a circular, sinusoidal pattern like it's circling the earth; Worse with EtOH; no effect from beta-blocker

cerebellar tremor

rhythmic, repetitive, bizarre movements chiefly involving face, mouth, jaw, tongue. Tardive is slow mvmts which can be 2ndary to meds used to treat schizo like Thorazine or Haldol (still used today); usually involves just face and tongue, not the limbs

oral facial dyskinesia

- loss or impairment of voluntary action
- classically with a stroke, with a smile only one side is lifted, or with Bell's Palsy; usually damage to central or peripheral nerve

very common, twitchy, clearing your throat or blinking your eyes; if they become anxious or stressed, the tic manifests with greater frequency; there s no treatment, but Marinol (marijuana drug) has shown some improvement; Ex: Tourette's

tics

twitch right before you fall off to sleep; or generalized, Grand Mal seizure: flexion, extension of extremities

shock like movements, like with a seizure

myoclonus

ask pt to hold their arms/hands out and their hands flop down, called liver flop b/c if you have acute encephalopathy and high ammonia levels, AMS, one of your exam findings will be this flapping action

asterixis

AKA scissor gait, specifically in pt s who have recovered from a stroke; one arm/hand/fingers slightly flexed (stroke on that side), they fling their affected leg around because they ve lost dexterity to lift leg/foot/ankle and bring it down gently, so they used larger muscles of hip and torso to lift leg and bring it forward

Ex: stroke

spastic gait

assoc d with a foot drop; not a stroke or problem in brain, but a lumbar disc problem affecting L5 peripheral nerve that affects your foot/great toe; they can t lift up on their foot; pt c/o shooting pain down one leg and tripping over their foot; called marching gait b/c it slaps down on the ground b/c you can t elevate that foot appropriately; toes land first

Assoc'd with lumbar disc herniation

steppage gait

sensory nerves of periphery (diabetic polyneuropathy or B12 polyneuropathy resulting in lack of sensation in the feet; walk with a wide gait and SLAM their feet down hard b/c their forcing vibration into those nerve endings to tell them where to place their feet; +Romberg s eyes closed, arms out, they are unstable b/c their feet can t tell where they are in space; tend to look down to see where they re going

sensory ataxia

Staggering, widebased, unsteady: get out of bed and they fall back, or just to one side.

Ex: if you ve had a stroke to this area, MCC

cerebellar ataxia

just from old age, decreased strength, walk more slowly, wide-based, tend to be hunched over, just to try to be stable

senile gait

rigid, short steps, quick shuffling steps, gradually faster shuffles and looks like they re going to run into you; Perched forward, very stiff, tend to stick their chin out. Stiff turns

Ex: Parkinson's!!!

Festinating

Parkinson's pathophys is a lack of... in the...

dopamine in the substantia nigra

This finding is assoc'd with Parkinson's . There is a development of these hyalin things, a hard encapsulation around neurons that prevent continued production of dopamine

No real meds, could use anti-psychotic to help with mvmt disorders, but you can t control the progression

prognosis for Huntington's

long, progressive, disabling course (10-25yrs)

lose ability to fxn independently, must institutionalize

Definition of seizure

a sudden, abnormal, and excessive discharge of neurons resulting in a clinical event

May have altered consciousness

May have motor/sensory phenomena

May have unusual cognitive perceptions

what are the 2 types of seizures?

partial

generalized

partial or generalized:

Focal, Localization-related

Origin: a point in the cerebral cortex

Consciousness maintained

Lasting seconds to minutes

Unilateral

Symptoms correspond to the location in brain

partial

your seizure pt is having jerking of the left arm. where is his lesion and is this partial or generalized?

R sided brain lesion, partial

are partial seizures unilateral or bilateral?

unilateral

symptoms correspond to the location in the brain

Partial seizure (simple or complex) or

Generalized seizures (grand or petit mal):

your pt is having paresthesias of left arm

or twitching of face

or entire side of body is twitching ("Jacksonian March")

simple partial

Partial seizure (simple or complex) or

Generalized seizures (grand or petit mal):

Your pt has AMS and is doing chewing motions

Complex partial (aka temporal lobe)

May also have a strange sense of unfamiliarity, opposite of D�j� vu

Depersonalization: step outside of body as a 3rd party observing

Originate in temporal lobe in hippocampus

can your pt have a partial seizure with secondary generalization?

yes, there is cortical spread deep to the diencephalon, then transferred to all parts of brain

Partial seizure or

Generalized seizures:

lost consciousness, bilateral and symmetric shaking

lasts seconds to minutes

generalized

Both sides involved b/c it s deep in brain, diencephalon spreads to both sides

when is the usual onset of generalized seizures? what age?

onset usually in childhood

Grand mal seizure is AKA...

generalized tonic clonic

Partial seizure (simple or complex) or

Generalized seizures (grand or petit mal):

Your pt presents with evidence of tongue biting, incontinence, and they have post icthal confusion. The mom states pt had a sudden loss of consciousness and then rigid and contracted muscles followed by jerking muscles.

grand mal (aka generalized tonic clonic)

which is tonic and which is clonic:

-jerking

-all muscles are rigid and contracted

Tonic: all muscles are rigid and contracted

Clonic: jerking

which type, Grand mal or petit mal, affects children and usually resolves by adulthood?

absence, aka Petit mal

Partial seizure (simple or complex) or

Generalized seizures (grand or petit mal):

affects children

lost consciousness

body posture and tone is maintained

smacking the lips or chewing or blinking the eyes

Petit mal, aka Absence seizure

5 item DDX for seizures

1. syncope

2. migraine aura

3. TIA

4. panic attack

5. seizure

Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:

lost consciousness, within a minute afterwards, you are yourself and not post-icthal state

syncope

Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:

see lights or smells

migraine aura

Out of the seizure DDX list (syncope, migraine aura, TIA, panic attack, seizure), what is this:

may last 5min to several hours, accompanied by paresthesias and numbness

TIA

seizure is usually shorter-lived

in the diagnostic workup of seizures, which imaging do you want to get now and which one do you want to get soon?

CT now (check for lesion)

MRI soon (regardless of CT is normal)

name some first genration AEDs and their 2 main problems

Phenobarbitol

phenytoion (Dilantin)

carbamazepine (Tegretol)

Valproic acid (Depakote)

problems: toxicity, drug interactions

this first generation AED lowers your IQ

phenobarbitol

name some second generation AEDs and the benefits of some

gabapentin

lamictal

Keppra

benefits: same efficacy as 1st gen; fewer SE; fewer DIs

What are the 2 characteristics of status epilepticus?

an unrelenting seizure:

-lasting >20 minutes or

-successive seizures without an interictal period

what 2 types of seizures may develop into SE?

tonic clonic (Grand Mal)

Absence (Petit mal)

Name some physical interventions and drug therapies for treatment of SE

physical:

-prevent pt from injury

-maintain airway w/o obstruction

-prevent aspiration

Drug Therapy:

-Ativan IV

-Dilantin IV

-Valium rectal gel

-Thiamine, glucose to treat acidosis

A localization-related seizure is also known as a __ seizure. It has focal manifestation in the body caused by a focal abnormality in the brain

partial

What differentiates a complex seizure from a simple seizure?

LOC

Movements in a complex partial seizure are (coordinated/random jerking)?

coordinated

During a seizure, actions such as lip-smacking, blinking, or chewing are known as___

automatisms

bilateral and symetric movements are characteristic of a (partial/generalized) seizure?

generalized

You examine a pt 10 minutes after a generalized seizure. Name some signs you expect to see on PE.

tongue biting

incontinence

post-ictal confusion

febrile seizures are more typical of (adults/children)?

children

seizures due to alcohol withdrawal typically begin how long after the last drink?

12-24 hours

trauma may produce seizures, especially head trauma with what features?

hemorrhage

skull fracture

LOC

weakness of an arm after a seizure would be an example of "__ paralysis"

Todd's paralysis

Which of these features are suggestive of seizure rather than syncope? (focal neurologic deficit/cardiac arrhythmia/carotid disease/history of malignancy / urinary incontinence/tongue lacerations)

focal deficit

history of malignancy (with new brain met)

incontinence

tongue lac

Which is more sensitive imaging study for evaluation of an anatomic brain lesion in a seizure pt? (LP/EEG /CT /MRI)

MRI

What study is the most important diagnostic tool for definitive evaluation of seizure type? (LP/ EEG/ CT /MRI)

EEG

If seizures are not well controlled on an AED, what would be the next step? (increase dose if possible/add second agent/switch to a different anticonvulsant)

maximize the dose

Drug interactions with AEDs are common and are often due to inducing or inhibiting what metabolic pathway?

CYP 450

oral contraceptives may be (more/less) effective in a pt on an anticonvulsant

Local mass effect of intracranial tumors: pushes other brain structures out of the way; clinical result is ___

focal neurologic deficit (this tumor may cause L sided weakness)

Midline shift from intracranial tumor: mass is so large that it pushes whole contents of brain from right to left; its effect clinically: ___

decreased level of consciousness

UNCAL ("transtentorial") herniation: the uncus (medial aspect) of temporal lobe is forced over the edge of the tentorium... eventually it compresses the brain stem and kills you. But before that, how does it present clinically?

Clinically: blown pupil; CN III branches off where the herniation is (medial temporal lobe), CNIII causes pupil to constrict, so with CNIII compression, you ll have unopposed dilatation

both upper and lower motor neuron spinal tumors present with these 2 ssx

This type of pituitary adenoma presents with bitemporal hemianopsia. Accompanying the visual changes is hypopituitary fxn

non-secreting

This type of pituitary adenoma causes amenorrhea and galactorrhea in females and decreased libido and impotence in males

secreting prolactinoma

what are the 3 types of secreting pituitary adenomas?

1. proliactinoma

2. GH secreting (Acromegaly)

3. ACTH secreting (Cushing's Dz)

this type of pituitary adenoma causes acromegaly

GH secreting pituitary adenoma

this type of pituitary adenoma causes Cushings Disease

ACTH secreting

Most common peripheral nerve tumor in the head

acoustic neuroma

classic triad of ssx for acoustic neuroma?

1. unilateral hearing loss

2. tinnitus

3. vertigo

Your pt presents with:

1. unilateral hearing loss

2. tinnitus

3. vertigo

Dx?

acoustic neuroma

what other CN ssx (2) may accompany acoustic neuroma?

CN VII - hemifacial weakness

CV V (hemifacial numbness)

what are the 3 most common primary sites for metastatic brain tumors?

lung

breast

melanoma

RCC

__% of spinal tumors are benign

60

3 classifications of spinal tumors

extradural

intradural, extramedullary

intradural, intramedullary

Which classification of spinal tumors:

Metastatic tumors

Hallmarks: cord compression, bony destruction

Symptoms: local back pain esp at night

extradural

which classification of spinal tumors:

Example: Schwannoma, meningioma

Symptoms: nerve root symptoms (radiculopathy)

intradural, extramedullary

which classification of spinal tumors:

Glioma

Ependymoma (line the ventricles, classic location is at the end of the spinal cord, L1)

Astrocytoma

Symptoms: cord compression (myelopathy) or nerve root (radiculopathy)

intradural, intramedullary

where is the classic location for an ependymomal glioma spinal tumor? (intradural, intramedullary)

ependymal cells line the ventricles, so as they combine with the spinal cord, gravity pulls them down toward the end of the spinal cord, classic location is at end of spinal cord at L1

You find a clump of abnormal tissue at the end of the spinal cord, what classification is it almost always?

ependymoma (intradural, intramedullary)

the most common solid tumor of childhood

brain tumors from leukemia

in childhood brain tumors, the majority are supra-or infratentorial?

infratentorial

A 12 y/o awakes with a HA most mornings for 2 weeks. Funduscopic exam shows papilledema, and a CT scan shows a mass causing an obstructive hydrocephalus. Based on these findings, and knowing the incidence of various tumors in children, you are not surprised at the location in the

a. supratentorial compartment

b. infratentorial compartment

c. cervical spinal cord

d. cauda equina

b. infratentorial

A pt with visual field defects is found to have a pituitary tumor. The next step toward diagnosis of the tumor type would be a lab study of

a. CBC w/diff

b. serum checmistry panel

c. endocrine panel

d. osmolality of blood serum and urine

c. endocrine panel

Stereotactic radiosurgery (focused radiation) is an appropriate first line tx for

a. AV malformations

b. intracerebral hematoma

c. glioblastoma

d. pituitary adenoma

a. AV malformations

A pt reports mid back pain awakening him at 4am for 2 weeks. He has no prior muscular or skeletal complaints and denies trauma. PE shows point tenderness at the T7 spinous process, but no neurologic abnormalities. The imaging study you would order first would be

a. intravenous pyelogram

b. MRI

c. myelogram with post-myelogram CT

d. plain x-rays of T spine

d. plain x-rays of T spine

A 56 y/o man has imbalance after arising from a chair. W/u for postural hypotension was negative. Your exam demonstrates no ataxia, dysmetria or dysdiadochokinesis An MRI shows a mass in the infratentorial compartment, abutting the cerebellum and pons. Which study is most appropriate for further w/u of this tumor?

a. audiometry

b. formal visual field testing

c. endocrine studies including GH, prolactin, serum cortisol and TSH

d. CT scan of chest and abdomen

a. audiometry

This tumor accounts for 40-50% of all intracranial tumors. It arises from the supporting cells of the CNS. Complete resection is generally not possible because extensions of tumor penetrate surrounding brain tissue

a. glioma

b. meningioma

c. pituitary adenoma

d. acoustic neuroma

a. glioma

This tumor is well circumscribed, generally benign, and amenable to total resection. Recurrence is uncommon. It arises from the arachnoid. It is more prevalent in females than males.

a. glioma

b. meningioma

c. pituitary adenoma

d. acoustic neuroma

b. meningioma

A pt complains of low back pain radiating to the right posterior thigh, with numbness at the right heel and lateral foot for several months. Now for 2 days he has new scrotal numbness, difficulty initiating micturation, and incomplete voiding. The most significant PE to perform is